Ann Thorac Surg 2012;93:313-315. doi:10.1016/j.athoracsur.2011.05.050
© 2012 The Society of Thoracic Surgeons
Case Reports
Successful Repair of an Atrioesophageal Fistula After Catheter Ablation for Atrial Fibrillation
Kara A. Haggerty, BAa,
Timothy J. George, MDa,
George J. Arnaoutakis, MDa,
Christopher J. Barreiro, MDa,
Ashish S. Shah, MDa,
Marc S. Sussman, MDb,*
a Division of Cardiac Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryand
b Division of Thoracic Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryand
Accepted for publication May 13, 2011.
* Address correspondence to Dr Sussman, Division of Surgery, Johns Hopkins Bayview Medical Center, 4940 Eastern Ave, Baltimore, MD 21224 (Email: msussma1{at}jhmi.edu).
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Abstract
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Catheter ablation of arrhythmias can result in the rare but devastating complication of an atrioesophageal fistula. This complication can be associated with significant neurologic morbidity and high mortality and requires a high index of suspicion to facilitate life-saving surgical intervention. Herein, we report the successful repair of an atrioesophageal fistula after catheter ablation for atrial fibrillation.
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Introduction
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Catheter radiofrequency ablation (RFA) is a common treatment for refractory atrial fibrillation (AF). Although relatively safe, with an incidence of complications around 6% [1], thermal injury to the esophagus can result in the development of an atrioesophageal fistula (AEF). While rare, AEF is a potentially lethal complication associated with significant neurological morbidity and 70% to 80% mortality [1–3]. Despite a consensus that prompt surgical repair is critical for survival, even early operative intervention can fail to prevent death [4]. Additionally, neither the optimal operative approach, the need for cardiopulmonary bypass (CPB), nor the type of repair of either the atrium or the esophagus has been established. We report a case of successful repair of an AEF after RFA of AF.
A 27-year-old man with a history of paroxysmal AF underwent an uncomplicated pulmonary vein RFA. At the time of ablation, esophageal temperature was monitored. Twenty-two days postprocedure, the patient presented with a fever, chills, hypotension, and hematemesis. A chest computed tomography scan revealed pneumomediastinum directly adjacent to the left atrium (LA) concerning for esophageal perforation (Fig 1
). A subsequent barium swallow was positive for contrast extravasation. Given the high suspicion of AEF, the patient was transferred to the Johns Hopkins Hospital for definitive surgical treatment. Given his persistent hematemesis and hemodynamic instability, he was taken emergently to the operating room.
The patient was placed in the left lateral decubitus position with his groin exposed for possible peripheral CPB. A right posterolateral thoracotomy was performed through the fifth intercostal space to allow for aortic cross clamping and initiation of CPB if necessary. The pleura overlying the esophagus caudal to the inferior pulmonary vein was divided to expose the esophagus. Under direct visualization, a scope was placed in the esophagus to facilitate exposure. Insufflation did not occur until after esophageal repair. Below the carina, the esophagus was densely adherent to the posterior LA. Lysis of adhesions exposed the AEF and resulted in significant bleeding from the LA. The patient was placed on CPB via the right femoral artery and vein. The heart was allowed to beat and neither cardioplegic arrest nor fibrillation were used. Once on bypass, exploration of the LA revealed a large atrial defect near the pulmonary vein. Due to the close proximity of the pulmonary vein, the LA was repaired with a bovine pericardial patch sewn in with 4-0 Prolene. The patient was then separated from bypass without difficulty and without evidence of intracardiac air. Carbon dioxide was used in the field. The patient remained in sinus rhythm throughout.
To properly define the esophageal injury, the esophagus was insufflated with the esophagoscope, revealing a 2 mm defect. The defect was repaired with 2 layers of interrupted 4-0 silk sutures. To separate the atrial and esophageal repairs, a pedicled intercostal muscle flap was harvested from the fifth intercostal space and tacked to the esophageal repair with 4-0 silk sutures. The chest was drained with two Blake drains and a 32F chest tube and a nasogastric tube was inserted under direct visualization to decompress the stomach. The chest was closed in standard fashion and the patient was transferred to the intensive care unit in stable condition. A transthoracic echocardiogram performed immediately postoperatively demonstrated excellent left ventricular function and no aortic valve insuffiency.
On postoperative day 4, a cine-esophagogram demonstrated resolution of the fistula (Fig 2
) at which point oral intake was reinstituted. The patient's postoperative course was notable for mild acute renal failure which resolved with conservative management. The patient was discharged home on postoperative day 13 with a 4-week course of antibiotics and was found to be doing well in our clinic a month after his operation.
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Comment
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We report a case of successful repair of an AEF after RFA for AF. RFA of the atrial wall is an increasingly common treatment for arrhythmias [5]. Although a generally safe procedure, the increasing frequency has revealed some rare but devastating complications. While uncommon, thermal injury to the esophagus is possible secondary to the proximity of the posterior LA wall to the esophagus [4], the thin atrial wall [4], and the absence of pericardium in this area [6]. Mild thermal injury to the esophagus occurs in 2.9% of patients but can develop into an AEF in less than 1% of patients undergoing RFA [7]. Although rare, development of AEF is often fatal with a mortality rate greater than 70% [1].
As a rare but potentially fatal complication of RFA, a high index of suspicion is necessary to facilitate prompt diagnosis and emergent surgical repair. In this case, the patient presented 3 weeks after his ablation with fever, chest pain, hypotension, and frank upper gastrointestinal bleeding. Other presenting symptoms that have been reported include fever [5, 6, 8], chest pain [4, 8], arrhythmias [4], altered mental status [2], seizures [2, 4, 8], and focal neurologic deficits [5, 6]. These symptoms mimic more common conditions including infective endocarditis, cerebrovascular accidents, and gastrointestinal causes of bleeding. Any patient exhibiting fever, bleeding, or neurologic symptoms after RFA should be evaluated for AEF to facilitate prompt treatment.
While most clinicians would agree that prompt surgical intervention is critical to survival, there is no consensus on the optimal operative approach. We believe that immediate surgery is most likely to result in survival and most reported cases of esophageal stenting have resulted in failure [6]. Several authors have reported approaching AEFs through a left thoracotomy [5, 6], but to our knowledge, we are the first to report a successful repair through a right posterolateral thoracotomy. Exposure from the right side of the chest would allow aortic cross clamping if necessary, although we did not have any problems with intracardiac air or exposure to complete the repair. Additionally, as others have suggested, we believe it is important to have CPB available [5, 6, 8]. Fistula take-down can result in significant atrial bleeding. While standard CPB cannulation has been reported [8], we believe that preparing the groin allows for an attempt at off-bypass repair while simultaneously facilitating emergent CPB if necessary.
Although we used an esophagoscope to facilitate exposure, given the risk of aggravating the injury, dislodging a clot, or causing an air embolism, the benefit of improved exposure must be carefully weighed against the potential risks.
In our patient, a bovine pericardial patch was used for repair because of the close proximity between the atrial defect and the pulmonary vein. Successful primary repair with pledgeted sutures and reinforcement with pericardial patching have also been reported [6, 8]. After primary repair of the esophagus, we interposed an intercostal muscle flap. Although we are unaware of any reported cases of re-fistulization between the atrial and the esophageal repairs, we feel that maintaining a physical separation with a muscle flap or pericardial patch is important to avoid this possible complication.
Finally, in many previously reported cases, patients died before reaching the operating room [2, 8] or after successful repair [4, 7]. Prompt surgical intervention is crucial for survival. Additionally, our patient did not have neurologic symptoms, suggesting early diagnosis may avoid air and bacterial embolization that can result in severe sepsis and devastating neurological injury.
In conclusion, we report the successful repair of an AEF after RFA for AF. AEF remains a rare but devastating complication of RFA. While prompt diagnosis and emergent surgical intervention are crucial for survival, the presenting symptoms can be easily confused with more common problems. Thus a high index of suspicion for AEF in patients after RFA is important for survival.
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References
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- Cappato R, Calkins H, Chen SA, et al. Prevalence and causes of fatal outcome in catheter ablation of atrial fibrillation J Am Coll Cardiol 2009;53:1798-1803.[Medline]
- Baker MJ, Panchal PC, Allenby PA. Life-threatening GI hemorrhage caused by atrioesophageal fistula: a rare complication after catheter ablation for atrial fibrillation Gastrointest Endosc 2010;72:887-889.[Medline]
- Stollberger C, Pulgram T, Finsterer J. Neurological consequences of atrioesophageal fistula after radiofrequency ablation in atrial fibrillation Arch Neurol 2009;66:884-887.[Medline]
- Borchert B, Lawrenz T, Hansky B, Stellbrink C. Lethal atrioesophageal fistula after pulmonary vein isolation using high-intensity focused ultrasound (HIFU) Heart Rhythm 2008;5:145-148.[Medline]
- Khandhar S, Nitzschke S, Ad N. Left atrioesophageal fistula following catheter ablation for atrial fibrillation: off-bypass, primary repair using an extrapericardial approach J Thorac Cardiovasc Surg 2010;139:507-509.[Free Full Text]
- Cazavet A, Muscari F, Marachet MA, Leobon B. Successful surgery for atrioesophageal fistula caused by transcatheter ablation of atrial fibrillation J Thorac Cardiovasc Surg 2010;140:43-45.
- Gilcrease GW, Stein JB. A delayed case of fatal atrioesophageal fistula following radiofrequency ablation for atrial fibrillation J Cardiovasc Electrophysiol 2010;21:708-711.[Medline]
- Pappone C, Oral H, Santinelli V. Atrio-esophageal fistula as a complication of percutaneous transcatheter ablation of atrial fibrillation Circulation 2004;109:2724-2726.[Abstract/Free Full Text]
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Abstract
Introduction
